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A study commissioned by the U.S. House of Representatives Committee on Oversight and Government Reform concluded that U.S. hospital surge capacity is inadequate to deal with the "predictable surprise."

On March 11, 2004, on the eve of a major election in Spain, an attack on commuter trains in Madrid killed 177 instantly and injured more than 2,000. Nearly one thousand patients were transported to 15 hospitals. In less than three hours, 270 patients arrived at a single hospital in Madrid.

The Centers on Disease Control and Prevention says that a terrorist bombing in the United States like the one in Madrid is a "predictable surprise." According to the CDC, the 2004 Madrid bombing is an appropriate standard for assessing whether the emergency care system in the United States is prepared to respond to a terrorist attack.

At the request of Chairman Henry A. Waxman, the majority staff of the Committee conducted a survey of Level I trauma centers in seven major U.S. cities to assess whether they have the capacity to respond to the level of casualties experienced in the Madrid attack. The survey included five of the cities considered at highest risk of a terrorist strike: New York City, Los Angeles, Washington, D.C., Chicago, and Houston. It also included Denver and Minneapolis, sites of the 2008 national political conventions.

The Level I trauma centers surveyed are not the only providers of emergency care in the seven cities, but they are the hospitals that can provide the highest levels of injury care and would be the preferred destinations for casualties in the event of a terrorist attack involving conventional explosives. Severely injured patients treated at Level I trauma centers have a significantly lower risk of death than patients treated at hospitals that are not trauma centers.

The survey was conducted on Tuesday, March 25, 2008, at 4:30 p.m. local time in each of the seven cities. The survey was designed to determine the real-time capacity of the emergency rooms at the Level I trauma centers to absorb a sudden influx from a mass casualty event. Thirty-four of the 41 Level I trauma centers in these cities participated in the survey.

The results of the survey show that none of the hospitals surveyed in the
seven cities had sufficient emergency care capacity to respond to an attack generating the number of casualties that occurred in Madrid. The Level I trauma centers surveyed had no room in their emergency rooms to treat a sudden influx of victims. They had virtually no free intensive care unit beds within their hospital complex. And they did not have enough regular inpatient beds to handle the less severely injured victims. The shortage of capacity was particularly acute in Los Angeles and Washington, D.C.

Significant conclusions:

• More than half of the emergency rooms in the Level I trauma centers surveyed were operating above capacity. When an emergency room reaches “capacity,” new patients can be accommodated only in overflow spaces, such as hallways, waiting rooms, or administrative offices. Of the 34 Level I trauma centers surveyed, 20 (59%) were operating over capacity, meaning they had no available treatment space in the emergency room to accommodate new patients. The average emergency room was operating at 115% of capacity in the Level I trauma centers in the seven cities.

• The total number of available emergency room treatment spaces in each of the seven cities was less than the number treated at a single Madrid hospital. After the Madrid attack, 966 victims were transported to 15 hospitals, and 270 victims arrived at a single hospital for emergency care. Not one of the seven cities had sufficient treatment spaces in emergency rooms of their Level I trauma centers to handle the volume of victims seen at a single Madrid hospital. Across all hospitals surveyed in New York City, the city with the most available emergency room space, there were only 56 emergency room treatment spaces available in the Level I trauma centers. All the other cities had even less available emergency room treatment space in their Level I trauma centers.

• In Los Angeles, three of the five hospitals surveyed were on diversion. Because Level I trauma centers represent such a vital resource for trauma patients, these hospitals are not supposed to divert ambulances unless they are dangerously overcrowded. On the afternoon of the survey, however, three of the five Level I trauma centers in Los Angeles were on diversion. Together, these five Level I trauma centers had only six vacant treatment spaces available in their emergency rooms at the time of the survey.

• In Washington, D.C., there were no available spaces in the emergency rooms of the two Level I trauma centers surveyed. Two of the three Level I trauma centers in the nation’s capital responded to the survey: the Washington Hospital Center and the George Washington University Medical Center. The emergency rooms in both hospitals were severely overcrowded at the time of the survey, with no available treatment spaces. The emergency room at the Washington Hospital Center was operating at 286% of capacity, making it the single most overcrowded hospital surveyed.

Surge capacity depends on more than sufficient space in the emergency room. A hospital must also be able to provide sufficient critical care resources, such as space in intensive care units, and inpatient beds. If these beds are not available, patients who require hospitalization are frequently “boarded” in the emergency room until they can be moved to an intensive care unit or inpatient bed. On the day of the survey, there were such severe shortages of critical care and inpatient beds that many of the hospitals we surveyed were already “boarding” admitted patients in their emergency room.

• None of the Level I trauma centers surveyed had enough critical care capacity available for seriously injured casualties from a Madrid event. After the Madrid attack, 29 patients arrived at one hospital in critical condition. None of 34 Level I trauma centers surveyed had sufficient critical care capacity to handle this volume of severely injured victims. On average, the trauma centers surveyed had only five intensive care unit beds available. Six hospitals (18%) had no available intensive care unit beds.

• None of the Level I trauma centers surveyed had a sufficient number of regular inpatient beds available to absorb the casualties from a Madrid event. In Madrid, a single hospital received 89 casualties that required admission to an inpatient bed. No Level I trauma center surveyed had sufficient available beds to accommodate a surge of this size. On average, the Level I trauma centers had only 24 beds available.

After conducting the “snapshot” survey on March 25 at 4:30 p.m., the Committee staff sent follow-up questionnaires to the hospitals surveyed. Twenty-three of the hospitals responded to the questionnaire. Their responses indicate that the level of emergency care they can provide is likely to be further compromised by three new Medicaid regulations, the first of which takes effect on May 26, 2008. According to these hospitals, the new Medicaid regulations will reduce federal payments to their facilities by $623 million per year. If the states choose to withdraw their matching funds, the hospitals could face a reduction of about $1.2 billion. The hospitals told the Committee that these funding cuts will force them “to significantly reduce services” in the future and that “loss of resources of this magnitude inevitably will lead to curtailing of critical health care safety net services such as emergency, trauma, burn, HIV/AIDS, neonatology, asthma care, diabetes care, and many others.”